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Rodrigues Pereira RP, Mazzali Pessoa Martins AM, Mendes de Carvalho IT, Kel de Souza LD, Francao P, Gomes CM, Bernardes RDP, Meyer KF, Fonseca EMGOD, Machado MG, Tanaka C. Clinical phenotyping of children with nocturnal enuresis: A key classification to improve the approach. J Pediatr Urol 2024; 20:384.e1-384.e9. [PMID: 38508980 DOI: 10.1016/j.jpurol.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 12/01/2023] [Accepted: 01/19/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION The literature shows that nocturnal enuresis is not an isolated phenomenon of urinary loss during sleep, but encompasses a set of systemic clinical manifestations that significantly influence children's quality of life and development. However, the understanding of the clinical and physiological relationship of these systemic manifestations remains a clinical challenge. The recognition of these manifestations and their subsequent categorisation, may provide better insights into integrated clinical manifestations, facilitating the understanding of pathophysiological mechanisms, and promote increased assertiveness in the assessment and the selection of appropriate therapies. OBJECTIVE The aim of this study is to develop a phenotyping model for children with nocturnal enuresis based on evidence. METHODS This study presents a clinical phenotyping model for children with nocturnal enuresis based on an analytical and methodological review of the literature, about nocturnal enuresis and its associated clinical manifestations. There was a bibliometric analysis carried out to better analyse outcomes. After reading and analysing the literature, the clinical manifestations were categorised into domains and submitted to the validation of an expert committee with extensive experience in their specific area of expertise. A visual representation of the categorised model was developed to make the phenotyping concept easily understandable to all professionals. RESULTS The clinical manifestations related to nocturnal enuresis have been categorised according to frequency and relation found in the literature and validation by an expert committee and the development of the phenotyping model for children with nocturnal enuresis was completed. CONCLUSION The present study developed an evidence-based phenotyping model for children with nocturnal enuresis.
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Affiliation(s)
- Rita Pavione Rodrigues Pereira
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
| | - Aline Mari Mazzali Pessoa Martins
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
| | - Isabela Teixeira Mendes de Carvalho
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
| | - Luana Daniele Kel de Souza
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
| | - Patricia Francao
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
| | - Cristiano Mendes Gomes
- Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil.
| | | | | | - Eliane Maria Garcez Oliveira da Fonseca
- Departamento de Pediatria, Núcleo de Disfunção Miccional, Faculdade de Ciências Médicas da Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil; Departamento de Pediatria da Escola de Medicina Souza Marques, Rio de Janeiro, Brazil.
| | - Marcos Giannetti Machado
- Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil.
| | - Clarice Tanaka
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil; LIM 54 - Laboratório de Investigação em Fisioterapia, Hospital das Clínicas da Faculdade de Medicina da Universidade De São Paulo, Sao Paulo, SP, Brazil.
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Sirimongkolchaiyakul O, Sutheparank C, Amornchaicharoensuk Y. The Prevalence of Nocturnal Enuresis in Bangkok, Thailand: A Descriptive and Questionnaire Survey of 5 to 15 Year-Old School Students. Glob Pediatr Health 2023; 10:2333794X231189675. [PMID: 37533961 PMCID: PMC10392157 DOI: 10.1177/2333794x231189675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023] Open
Abstract
Objectives. Nocturnal enuresis (NE) is a common problem among school-aged children. Nonetheless, further information on NE prevalence in Thailand is needed. The prevalence of NE and factors associated with it were investigated. Methods. A descriptive study was conducted in schools in Bangkok, Thailand, among children aged 5 to 15 years, using a questionnaire survey between November 2018 and July 2019. Results. The prevalence of primary monosymptomatic, primary nonmonosymptomatic, and secondary NEs was 9.7%, 11.6%, and 8.2%, respectively. Primary NE was associated with a family history of NE (OR = 4.05, P < .001), drinking within 2 hours before bedtime (OR = 1.77, P = .01), and deep sleep (OR = 1.62, P = .001). Conclusion. Primary NE was prevalent in this setting, and the most related factor was a family history of NE. Parents should be aware of NE in their children, especially if a child has a linked factor.
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Affiliation(s)
- Ornatcha Sirimongkolchaiyakul
- Faculty of Medicine, Division of Nephrology, Department of Pediatrics, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chanon Sutheparank
- Faculty of Medicine, Department of Pediatrics, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Yupaporn Amornchaicharoensuk
- Faculty of Medicine, Division of Nephrology, Department of Pediatrics, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Jie LP. Clinical observation on the efficacy of Tongdu Tuina manipulation in the treatment of primary enuresis in children. Open Med (Wars) 2023; 18:20230712. [PMID: 37398900 PMCID: PMC10314128 DOI: 10.1515/med-2023-0712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/15/2023] [Accepted: 04/13/2023] [Indexed: 07/04/2023] Open
Abstract
The objective was to explore the efficacy of Tongdu Tuina manipulation in the treatment of primary single-symptom enuresis in children. A total of 102 children aged 5-16 with primary single-symptom enuresis were included in this study and randomly assigned to the Tuina group, the medication group and the control group, with 34 children in each group. The Tongdu Tuina group included manipulation of the Guanyuan, Qihai, Zhongji, Mingmen, kidney, Baihui, Sishencong and bladder acupoints, five times a week, the medication group was treated with 0.1 mg desmopressin acetate every night, and in the control group, the patients were given foods with high water content and underwent water deprivation 2 h before bedtime every night. The intervention time of each group was 1 month. The participants were followed up on Day 1 following treatment, as well as half a month, 1 month and 3 months after the implementation of the intervention measures, and the effective rate, the incidence of enuresis per week and the recurrence rate were calculated. As a result baseline demographic characteristics were comparable among 102 patients. Overall, 32 patients in the Tongdu Tuina group, 30 patients in the medication group and 34 patients in the control group completed the intervention. After half a month of treatment, there was no significant difference in the therapeutic efficacy among the three groups (P = 0.158), but each treatment could effectively reduce the frequency of weekly enuresis. The frequency of weekly enuresis in the Tongdu Tuina group was 3.8 ± 1.1 times, while that in the medication group was 4.0 ± 2.0 times. The frequency of weekly enuresis in the control group was 4.7 ± 1.8 times, and the difference was statistically significant (P = 0.016). After 1 month of treatment, the effective rates of the Tongdu Tuina group and the medication group were significantly increased (87.5% vs 83.33%, P < 0.0001), which was not the case with the control group. The frequency of enuresis was 1.9 ± 2.1 times per week in the Tongdu Tuina group, 2.4 ± 1.8 times per week in the medication group and 4.0 ± 0.9 times per week in the control group after 1 month of treatment. The difference between the three groups was statistically significant (P = 0.021), and there was a difference between the Tongdu Tuina group and the medication group (P < 0.0001). There was no significant difference between recurrence rate and the incidence of adverse events (P = 0.837, P = 0.856). In conclusion, both Tuina manipulation and desmopressin treatment can effectively improve children's primary single-symptom enuresis with safety. However, Tongdu Tuina therapy may be superior to desmopressin treatment.
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Affiliation(s)
- Li-Pu Jie
- Department of Paediatrics, The First People’s Hospital of Lanzhou, No. 1, Wujia West Street, Qilihe District, Lanzhou City, Gansu, 730050, China
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Ziaei E, Dorreh F, Yousefichaijan P, Sarmadian R, Sajjadi N, Kahbazi M. Evaluation of the association between asthma and non-neurogenic urinary incontinence in children; a case-control study. BMC Pediatr 2023; 23:141. [PMID: 36997891 PMCID: PMC10061945 DOI: 10.1186/s12887-023-03958-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Asthma is the most common chronic disease in children. Asthma can lead to sleep disorders and psychiatric issues, which are often accompanied by urinary incontinence in children. Furthermore, several studies have shown a relationship between allergic diseases and urinary incontinence. This study aims to examine the association between asthma and non-neurogenic urinary incontinence. MATERIALS AND METHODS This case-control study included 314 children over three years old referred to Amir Kabir Hospital; 157 with asthma and 157 without asthma. After explaining each urinary disorder in accordace with the International Children's Continence Society's definitions, parents and children were asked about their presence. The disorders included monosymptomatic nocturnal enuresis(MNE), nonmonosymptomatic nocturnal enuresis (NMNE), vaginal reflux (VR), pollakiuria, infrequent voiding, giggle incontinence (GI), and overactive bladder (OAB). The analysis was performed using Stata 16. RESULTS The average age of the children was 8.19 ± 3.15 years. Patients with asthma (p = 0.0001) and GI (p = 0.027) had a considerably lower average age than patients without these disorders. Asthma and urinary incontinence, including NMNE, Infrequent voiding, and OAB, were significantly correlated (p = 0.017, 0.013, and 0.0001, respectively). Moreover, the association between MNE and asthma was significant in males (p = 0.047). CONCLUSION Due to the relationship between asthma and urinary incontinence, children with asthma must be evaluated for the presence of urinary disorders and, if present, receive the proper treatment in order to improve their quality of life.
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Affiliation(s)
- Elaheh Ziaei
- Faculty of medicine, Arak University of Medical Sciences, Arak, Iran
| | - Fatemeh Dorreh
- Department of Pediatrics, Arak university of medical sciences, Arak, Iran
| | | | - Roham Sarmadian
- Infectious disease research center(IDRC), Arak university of medical sciences, Arak, Iran.
| | - Nooshin Sajjadi
- Department of Pediatrics, Arak university of medical sciences, Arak, Iran
| | - Manijeh Kahbazi
- Department of Pediatrics, Arak university of medical sciences, Arak, Iran
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Lee DG, Gui XY, Mukovozov I, Fleming P, Lynde C. Sleep Disturbances in Children With Atopic Dermatitis: A Scoping Review. J Cutan Med Surg 2023; 27:157-164. [PMID: 36880965 PMCID: PMC10068401 DOI: 10.1177/12034754231159337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Atopic dermatitis (AD) is associated with various quality of life concerns including poor sleep. Sleep impairments in children with AD are associated with increased risk of short stature, metabolic syndrome, mental illness and neurocognitive dysfunction. Although the association between AD and sleep disturbance is well established, the specific types of sleep disturbance in pediatric AD patients and their underlying mechanisms are not fully understood. A scoping literature review was performed to characterize and summarize the types of sleep disturbance in children (less than 18 years of age) with AD. 31 papers met inclusion criteria and extracted data were analyzed in an iterative manner. Two types of sleep disturbances were found to be more prevalent in pediatric AD patients in comparison to controls. One category was related to loss of sleep (increased frequency or duration of awakenings, increased sleep fragmentation, delayed sleep onset, decreased total sleep duration, and decreased sleep efficiency). Another category was associated with unusual behaviors during sleep (restlessness/limb movement/scratching, sleep-disordered breathing including obstructive sleep apnea and snoring, nightmares, nocturnal enuresis and nocturnal hyperhidrosis). Some mechanisms underlying these sleep disturbances include pruritus and induced scratching and increased proinflammatory markers induced by sleep loss. Sleep disturbance appears to be associated with AD. We recommend clinicians to consider interventions that may reduce sleep disturbances in children with AD. Further investigation of these sleep disturbances is needed to elucidate pathophysiology, develop additional treatments, and reduce negative impacts on the health outcomes and quality of life in pediatric AD patients.
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Affiliation(s)
- Dong Goo Lee
- 12358 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Xi Yao Gui
- 12358 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ilya Mukovozov
- 12358 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,12358 Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Fleming
- 12366 Division of Dermatology, University of Toronto, Toronto, ON, Canada
| | - Charles Lynde
- 12366 Division of Dermatology, University of Toronto, Toronto, ON, Canada.,The Lynde Institute for Dermatology, Markham, ON, Canada
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Effect of allergic rhinitis on sleep in children and the risk factors of an indoor environment. Sleep Breath 2022; 26:1265-1275. [DOI: 10.1007/s11325-021-02546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
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D'Elia C, Gozal D, Bruni O, Goudouris E, Meira E Cruz M. Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions. J Pediatr (Rio J) 2022; 98:444-454. [PMID: 34979134 PMCID: PMC9510807 DOI: 10.1016/j.jped.2021.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic. SOURCE OF DATA A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing. SYNTHESIS OF DATA Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent. CONCLUSIONS A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.
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Affiliation(s)
- Cláudio D'Elia
- Hospital Lusíadas, Departamento de Pediatria, Lisbon, Portugal; Centro Europeu do Sono, Portugal.
| | - David Gozal
- The University of Missouri School of Medicine, Child Health Research Institute, Department of Child Health, Columbia, United States
| | - Oliviero Bruni
- La Sapienza University, Department of Social Development and Psychology, Rome, Italy
| | - Ekaterini Goudouris
- Universidade Federal do Rio de Janeiro, Instituto Martagão Gesteira de Puericultura e Pediatria (IPPMG), Faculdade de Medicina, Departamento de Pediatria, Rio de Janeiro, RJ, Brazil
| | - Miguel Meira E Cruz
- Centro Europeu do Sono, Portugal; Lisbon School of Medicine, Sleep Unit, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
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Chen Y, Zhao A, Lyu J, Hu Y, Yin Y, Qu J, Tong S, Li S. Association of Parasomnia Symptoms with Risk of Childhood Asthma and the Role of Preterm Birth. Nat Sci Sleep 2022; 14:1559-1573. [PMID: 36089999 PMCID: PMC9451036 DOI: 10.2147/nss.s356182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To examine whether parasomnia symptoms are associated with increased odds of childhood asthma and wheeze, and the role of preterm birth. PATIENTS AND METHODS The Shanghai Children's Allergy Study was cross-sectionally conducted in 31 kindergartens and 17 primary schools in Shanghai, China. After excluding the missing data of gestational week and child's age, this study included a total of 16,487 individuals with a mean age of 7.74 years and 52.4% of males. The association between parasomnia symptoms and wheeze/asthma was assessed by univariate and multivariate analyses. The interaction effects of parasomnias and preterm birth were primarily evaluated by P for multiplicative interaction, and the relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP), and synergy index (SI) were also measured. RESULTS Parasomnias, especially rapid eye movement (REM) parasomnia symptoms, were associated with an increased risk of childhood wheeze/asthma, and the interaction between parasomnia and preterm birth exhibited an excess risk of current wheeze (RERI, 1.43; 95% CI, 0.41-2.45) and ever asthma (RERI, 0.75; 95% CI, 0.01-1.50). In the stratification analyses, the combination of parasomnia symptoms and preterm birth had higher odds of wheeze/asthma. And the odds of current wheeze (OR, 4.55; 95% CI, 1.69-12.25; p=0.003) and ever asthma (OR, 6.17; 95% CI, 2.36-16.11; p<0.001) were much higher in cumulative parasomnia symptoms plus very preterm birth. And sensitive analyses were further conducted in populations without sleep disordered breathing (SDB), and an allergen test subgroup, yielding similar results. CONCLUSION Parasomnia symptoms are associated with increased odds of childhood wheeze/asthma, and the odds were even higher in premature population. The findings suggest that parasomnia symptoms, as a developmental sleep disorder, are supposed to be closely watched among children who have asthma or are at risk for asthma, and that preterm children deserve more attention.
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Affiliation(s)
- Yiting Chen
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Anda Zhao
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jiajun Lyu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yabin Hu
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yong Yin
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jiajie Qu
- Childcare Department, Shanghai Municipal Education Commission, Shanghai, People's Republic of China
| | - Shilu Tong
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, People's Republic of China.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Shenghui Li
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,MOE-Shanghai Key Laboratory of Children's Environmental Health, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Banhara FL, Trindade IEK, Trindade-Suedam IK, Fernandes MDBL, Trindade SHK. Respiratory sleep disorders, nasal obstruction and enuresis in children with non-syndromic Pierre Robin sequence. Braz J Otorhinolaryngol 2021; 88 Suppl 1:S133-S141. [PMID: 34092522 PMCID: PMC9734268 DOI: 10.1016/j.bjorl.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/01/2021] [Accepted: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnea is highly prevalent in non-syndromic Pierre Robin sequence patients. Studies have found a probable relationship between obstructive sleep apnea and nasal obstruction and between obstructive sleep apnea and enuresis. Assessment of the relationship between these variables in non-syndromic Pierre Robin sequence patients is scarce. OBJECTIVE The present study aims to evaluate the relationship between symptoms of obstructive sleep apnea, nasal obstruction and enuresis, determining the prevalence of symptoms suggestive of these conditions, in schoolchildren with non-syndromic Pierre Robin sequence, and describe the prevalence of excessive daytime sleepiness habitual snoring and voiding dysfunction symptoms associated with enuresis. METHODS This was a prospective analytical cross-sectional study developed at a reference center. Anthropometric measurements and a structured clinical interview were carried out in a sample of 48 patients. The instruments "sleep disorders scale in children" "nasal congestion index questionnaire" (CQ-5), and the "voiding dysfunction symptom score questionnaire" were used. Statistical analysis was performed for p < 0.05. RESULTS Positive "sleep disorders scale in children" scores for obstructive sleep apnea and CQ-5 for nasal obstruction were observed in 38.78% and 16.33%, respectively. Enuresis was reported in 16.33% of children, being characterized as primary in 71.43% and polysymptomatic in 55.55%; according to the "voiding dysfunction symptom score questionnaire". There was a significant relationship between nasal obstruction and obstructive sleep apnea symptoms (p < 0.05), but no significance was found between obstructive sleep apnea symptoms and enuresis, and between nasal obstruction and enuresis. The prevalence of excessive daytime sleepiness was 12.24% and of habitual snoring, 48.98%. A family history of enuresis, younger age in years and a positive "voiding dysfunction symptom score questionnaire" score were associated with a higher prevalence of enuresis (p < 0.05). CONCLUSION Children with non-syndromic Pierre Robin sequence are at high risk for obstructive sleep apnea symptoms and habitual snoring, with a correlation being observed between nasal obstruction and obstructive sleep apnea symptoms. In addition, the study showed that non-syndromic Pierre Robin sequence, obstructive sleep apnea and nasal obstruction symptoms were not risk factors for enuresis in these patients.
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Affiliation(s)
- Fábio Luiz Banhara
- Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Unidade de Estudos do Sono do Laboratório de Fisiologia, Bauru, SP, Brazil,Corresponding author.
| | - Inge Elly Kiemle Trindade
- Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Unidade de Estudos do Sono do Laboratório de Fisiologia, Bauru, SP, Brazil,Universidade de São Paulo (USP), Faculdade de Odontologia de Bauru, Bauru, SP, Brazil
| | - Ivy Kiemle Trindade-Suedam
- Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Unidade de Estudos do Sono do Laboratório de Fisiologia, Bauru, SP, Brazil,Universidade de São Paulo (USP), Faculdade de Odontologia de Bauru, Bauru, SP, Brazil
| | - Marilyse de Bragança Lopes Fernandes
- Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Unidade de Estudos do Sono do Laboratório de Fisiologia, Bauru, SP, Brazil
| | - Sergio Henrique Kiemle Trindade
- Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Unidade de Estudos do Sono do Laboratório de Fisiologia, Bauru, SP, Brazil,Universidade de São Paulo (USP), Faculdade de Odontologia de Bauru, Bauru, SP, Brazil,Universidade de São Paulo (USP), Hospital de Reabilitação de Anomalias Craniofaciais (HRAC), Seção de Otorrinolaringologia, Bauru, SP, Brazil,Universidade Nove de Julho, Curso de Medicina, Bauru, SP, Brazil
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Sun C, Xu Y, Luo C, Li Q. Relationship between enuresis and obstructive sleep apnea-hypopnea syndrome in children. J Int Med Res 2020; 48:300060520977407. [PMID: 33290113 PMCID: PMC7727060 DOI: 10.1177/0300060520977407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We explored the relationship between enuresis and obstructive sleep apnea-hypopnea syndrome (OSAHS) in children and influencing factors of enuresis with OSAHS. METHODS We recruited 196 children ≥5 years old from the otolaryngology outpatient department, who experienced snoring and underwent nasopharynx lateral radiography and in-laboratory polysomnography. We analyzed correlations between the apnea-hypopnea index (AHI) and lowest oxygen saturation (L-SaO2) with age, body mass index (BMI), tonsil size, and adenoidal-nasopharyngeal (A/N) ratio using the Pearson correlation test. Differences in severe OSAHS prevalence, age, AHI, L-SaO2, tonsil size, and A/N ratio between children with and without enuresis were assessed using the chi-square test and t-test. Risk factors of enuresis were analyzed using logistic regression. Follow-up was conducted to assess remission in children with enuresis after adenotonsillectomy. RESULTS BMI, tonsil size, and A/N ratio were correlated with AHI and L-SaO2. Severe OSAHS prevalence, AHI, tonsil size, and A/N ratio were higher and L-SaO2 were lower in children with enuresis. Logistic regression showed that BMI, AHI, tonsil size, and sleep apnea were risk factors for enuresis. CONCLUSIONS Our study findings showed that enuresis was associated with OSAHS in children. Adenotonsillectomy may improve the symptoms of enuresis.
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Affiliation(s)
- Chen Sun
- Department of ENT, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yingpeng Xu
- Department of ENT, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chenxi Luo
- Department of ENT, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qi Li
- Department of ENT, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
- Medical School of Nanjing University, Nanjing, Jiangsu, China
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11
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The association between allergic rhinitis and sleep: A systematic review and meta-analysis of observational studies. PLoS One 2020; 15:e0228533. [PMID: 32053609 PMCID: PMC7018032 DOI: 10.1371/journal.pone.0228533] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/06/2020] [Indexed: 12/13/2022] Open
Abstract
This systematic review and meta-analysis examines the associations of allergic rhinitis with sleep duration and sleep impairment. Observational studies published before August 2019 were obtained through English language literature searches in the PubMed, Embase, and CINAHL databases. Mean differences and odds ratios with 95% confidence intervals were extracted and used for meta-analysis. Heterogeneity was confirmed by the I2-heterogeneity test. Subgroup analysis was conducted to evaluate the influence of study design. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to determine the level of evidence. In total, 2544 records were identified through database searches; 914 duplicate records were excluded, 1452 records were removed after screening of titles and abstracts, 151 records were excluded after full-text screening, and 27 articles were included in the final meta-analyses. A total of 240,706,026 patients (19,444,043 with allergic rhinitis) were considered. No significant difference in sleep duration between the allergic rhinitis and the control groups was found. Patients with allergic rhinitis presented with significantly higher sleep quality scores, sleep disturbances scores, and sleep latency scores; more frequent use of sleep medications; and lower sleep efficiency as measured by the Pittsburgh Sleep Quality Index and polysomnography. Meta-analyses for adjusted odds ratios showed that allergic rhinitis was also associated with higher risks of nocturnal dysfunctions, including insomnia, nocturnal enuresis, restless sleep, sleep-disordered breathing, obstructive sleep apnea, and snoring. Meta-analysis for adjusted odds ratio also showed that allergic rhinitis was associated with daytime dysfunction, including difficulty waking up, daytime sleepiness, morning headache, and the use of sleep medications. The overall quality of evidence ranged from low to very low, indicating that caution is required when interpreting these results. This study demonstrates that there is a significant association of AR with sleep characteristics.
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12
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Hsiao YC, Wang JH, Chang CL, Hsieh CJ, Chen MC. Association between constipation and childhood nocturnal enuresis in Taiwan: a population-based matched case-control study. BMC Pediatr 2020; 20:35. [PMID: 31992241 PMCID: PMC6986027 DOI: 10.1186/s12887-020-1939-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/22/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The relationship between constipation and childhood nocturnal enuresis (NE) has been previously reported; however, this relationship remains controversial. The present study aimed to evaluate the association between constipation and childhood NE. METHODS Data from the Longitudinal Health Insurance Database 2000 (LHID 2000) of Taiwan National Health Insurance Research Database from 2000 to 2013 were collected. A total of 2286 children were enrolled in this study: a case group of 1143 children aged 5-18 years who were diagnosed with NE (NE group) and an age- and sex-matched control group of 1143 children without NE. Conditional logistic regression and odds ratio (OR) for NE were used to examine the association between constipation and childhood NE. RESULTS The prevalence of NE in the case group (NE group, aged 5-18 years) was 1.03% from 2000 to 2013. The NE group had a higher percentage of constipation in 1 year before the diagnosis of NE. After stratification for sex, both boys and girls with constipation had higher OR for NE. With stratification for age, children aged 5-12 and 7-12 years had a higher OR for NE. CONCLUSIONS Constipation is associated with childhood NE in Taiwan, particularly in children aged 5-7 and 7-12 years.
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Affiliation(s)
- Yu-Chao Hsiao
- Department of Pediatrics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chia-Ling Chang
- Management Office for Health Data, Clinical Trial Research Center (CTC), China Medical University Hospital, Hongkong, China
| | - Chia-Jung Hsieh
- Department of Public Health, Tzu Chi University, Hualien, Taiwan
| | - Ming-Chun Chen
- Department of Pediatrics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan. .,School of Medicine, Tzu Chi University, No. 707, Section 3, Chung Yang Road, Hualien City, Hualien, Taiwan.
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13
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Su MS, Xu L, Pan WF, Li CC. Current perspectives on the correlation of nocturnal enuresis with obstructive sleep apnea in children. World J Pediatr 2019; 15:109-116. [PMID: 30446975 DOI: 10.1007/s12519-018-0199-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) and nocturnal enuresis (NE) are common clinical problems in children. OSA and NE are thought to be interrelated, but the exact pathophysiological mechanisms are not yet clear. This review aims to explain the possible pathogenesis of NE in children with OSA. DATE SOURCES We have retrieved all relevant original articles from Database that have been published so far, including the prevalence studies of NE and OSA in children, sleep characteristic studies that use polysomnography (PSG) to focus on children with NE, and studies on the relationship between OSA and NE. RESULTS Clinical studies have revealed that the risk of NE in children with OSA was increased compared with that of their healthy peers. This increased risk may be associated with sleep disorders, bladder instability, detrusor overactivity, nocturnal polyuria, endocrine and metabolic disorders, and inflammation. CONCLUSIONS Cardiopulmonary and renal reflex-induced neuroendocrine disorder may play an important role in the mechanism of NE in children with OSA, but this remains to be confirmed by animal studies. Other causes such as oxidative stress and inflammatory responses need to be further researched.
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Affiliation(s)
- Miao-Shang Su
- Department of Pediatric Respiratory Medicine and Sleep Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Li Xu
- Department of Pediatric Respiratory Medicine and Sleep Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Wen-Feng Pan
- Department of Pediatric Respiratory Medicine and Sleep Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Chang-Chong Li
- Department of Pediatric Respiratory Medicine and Sleep Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
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14
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Tzeng NS, Chung CH, Chang HA, Chang CC, Lu RB, Yeh HW, Chiang WS, Kao YC, Chang SY, Chien WC. Obstructive Sleep Apnea in Children and Adolescents and the Risk of Major Adverse Cardiovascular Events: A Nationwide Cohort Study in Taiwan. J Clin Sleep Med 2019; 15:275-283. [PMID: 30736877 DOI: 10.5664/jcsm.7632] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 11/15/2018] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVES This study has investigated the risk of major adverse cardiovascular events (MACEs), including acute myocardial infarction, coronary artery disease, peripheral artery disease, and acute stroke, among children and adolescents (age younger than 20 years) with obstructive sleep apnea (OSA). METHODS In this study, the population-based National Health Insurance Research Database of Taiwan was used to identify patients in whom OSA had been first diagnosed between 2000 and 2015. Children and adolescents with OSA (n = 6,535) were included with 1:3 ratio by age, sex, and index year of control participants without OSA (n = 19,605). The Cox proportional regression model was used to evaluate the risk of MACEs in this cohort study. RESULTS After a 15-year follow-up, the incidence rate of MACEs was higher in the OSA cohort when compared with the non-OSA control cohort (15.97 and 8.20 per 100,000 person-years, respectively). After adjusting for covariates, the risk of MACEs among children and adolescents with OSA was still significantly higher (hazard ratio = 2.050; 95% confidence interval = 1.312-3.107; P = .010). No MACEs were found in the children and adolescents with OSA who received continuous airway positive pressure treatment or pharyngeal surgery. CONCLUSIONS This study found a significantly higher risk of MACEs in children and adolescents with OSA. These findings strongly suggest that clinicians should provide careful follow-up and medical treatment for children and adolescents with OSA.
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Affiliation(s)
- Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan, ROC
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chuan-Chia Chang
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ru-Band Lu
- Department of Psychiatry, College of Medicine and Hospital, National Cheng-Kung University, Tainan, Taiwan, ROC.,Institute of Behavioral Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan, ROC
| | - Hui-Wen Yeh
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC.,Institute of Bioinformatics and System Biology, National Chiao Tung University, Hsin-Chu, Taiwan, ROC.,Department of Nursing, Tri-Service General Hospital, and School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC.,Department of Nursing, Kang-Ning University (Taipei Campus), Taipei, Taiwan, ROC
| | - Wei-Shan Chiang
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yu-Chen Kao
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC.,Department of Psychiatry, Tri-Service General Hospital, Song-Shan Branch, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shan-Yueh Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taiwan, ROC
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC.,Graduate Institute of Life Sciences, National Defense Medical Center, Taiwan, ROC
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Ferrara P, Autuori R, Dosa F, Di Lucia A, Gatto A, Chiaretti A. Medical Comorbidity of Nocturnal Enuresis in Children. Indian J Nephrol 2019; 29:345-352. [PMID: 31571742 PMCID: PMC6755928 DOI: 10.4103/ijn.ijn_319_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction: The purpose of this study was to evaluate the characteristics of patients with nocturnal enuresis (NE). Methods: We enrolled 403 children with NE referred to the Services of Pediatrics, Campus Bio-Medico University Hospital of Rome between June 2013 and July 2018. We excluded 2 children, respectively, with renal agenesis and chromosomopathy. Results: Of the 401 patients, 101 girls (25.2%) and 300 boys (74.8%), aged 5–16 years; mean age at first visit 8.8 ± 2.44 years. During the physical examination, we asked the patients and their parents specific questions to identify signs and symptoms of voiding disorders and comorbid conditions. In addition, we evaluated family history and behavioral characteristics of patients. In this study, NE was heredity in the 31.2% of cases. We found urogenital abnormalities in 15.7% of cases, constipation in 14.5% of cases, innocence heart murmur in 21.4% of cases and parasomnias in a good percentage of cases, especially snoring (13.7%), restless sleep (5.7%), somniloquy (23.7%) and bruxism (14.7%). Conclusions: Our experience demonstrates that there are a lot of comorbidities that are associated with NE and can influence the prognosis and the response to the therapy in these children.
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Affiliation(s)
- Pietro Ferrara
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy.,Service of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | - Roberta Autuori
- Service of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | - Flavia Dosa
- Service of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | | | - Antonio Gatto
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
| | - Antonio Chiaretti
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
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Wada H, Kimura M, Tajima T, Shirahama R, Suzuki Y, Suzuki Y, Hayashi T, Maruyama K, Endo M, Sakamoto N, Ikeda A, Gozal D, Tanigawa T. Nocturnal enuresis and sleep disordered breathing in primary school children: Potential implications. Pediatr Pulmonol 2018; 53:1541-1548. [PMID: 30203928 DOI: 10.1002/ppul.24156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/13/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The association between nocturnal enuresis (NE) and sleep disordered breathing (SDB) has been repeatedly reported, but has primarily been focused on clinical cohorts. The purpose of this study, was to assess whether SDB-related symptoms such as snoring and unrefreshing sleep in the morning are associated with NE in a large-scale community school-based survey. METHODS A cross-sectional assessment using a standard questionnaire was conducted on nearly 20 000 primary school children (5-12 years old) in Matsuyama, Japan. Associations between NE and the frequencies of snoring and unrefreshing sleep were evaluated using multivariate logistic and regression analyses. RESULTS Multivariate adjusted odds ratios (95% confidence intervals) for enuresis were 1.21 (1.04 to 1.40) and 1.36 (1.07 to 1.73) in boys who snored 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Those for enuresis were 1.67 (1.41 to 1.99) and 1.96 (1.63 to 2.36) in boys who showed unrefreshing sleep 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Significant associations between NE and snoring frequency emerged among children who did not report unrefreshing sleep (P-trend for boys and girls were <0.0001 and <0.01, respectively), while significant associations between NE and frequency of unrefreshing sleep were detected among children who snored ≥1 nights per week (P for trend >0.1). CONCLUSIONS The pathogenic mechanisms linking snoring and unrefreshing sleep to increased risk of NE are unknown. However, snoring, a surrogate reporter of SDB, is associated with increased urine production, while unrefreshing sleep may result from disrupted sleep facilitating increased sleep pressure and elevated arousal thresholds. Thus, both SDB and unrefreshing sleep are potential independent risk factors of NE in school age children.
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Affiliation(s)
- Hiroo Wada
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Manami Kimura
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Tomokazu Tajima
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Ryutaro Shirahama
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan.,RESM Shin Yokohama Clinic, Yokohama, Kanagawa, Japan
| | - Yohei Suzuki
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Yuka Suzuki
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Toshinari Hayashi
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan.,Tokorozawa Sleep and Respiratory Clinic, Tokorozawa, Saitama, Japan
| | - Koutatsu Maruyama
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan.,Department of Bioscience, Graduate School of Agriculture, Ehime University, Matsuyama, Ehime, Japan
| | - Motoki Endo
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Naoko Sakamoto
- Department of Epidemiologic Research, Toho University, Ohta-ku, Tokyo, Japan
| | - Ai Ikeda
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri
| | - Takeshi Tanigawa
- Department of Public Health, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
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